Cliff Reid and Geoff Healy discuss challenges in prehospital intraosseous and intravenous access, covering how to avoid pitfalls and what their own individual practice preferences are in the prehospital and in-hospital settings (22 mins).

6 Responses to Vascular & Osseous Access in Resuscitation

Nice post gentlemen teasing out vascular access. What we need is a Swan introducer sheath or the like. Issue is the packaging is very large and difficult to fit into kit-bag. Place it ipsilateral to blunt chest trauma side, contra-lateral to penetrating chest trauma side. In small kids- look for the ‘blue dot’ external jugular- 18Ga line. Trick for securing line in sweaty shocked patient: rub some betadine on the skin near line, dries fast and becomes sticky to allow securing dressing to stick.

Thanks for this post. I listened with interest during a quiet retrieval shift.
A sentinel case for me was the arrival of an obese female from an MVA in asystole who had been conscious a minute earlier. Her one peripheral IV had been pulled out so she had no access. She was so shocked her veins on u/s were flat. Tibial I/O attempted but at that stage we only had the pink and blue EZ IO needles. The blue was too short. We have the yellow now.
I was reluctant to remove the hard collar and go for a neck line but should have in retrospect. Anaesthetist attended and placed a RIJ CVC but she died.
Whist ultrasounding her femoral v which was not visible I saw the nice round muscular fem art and have wondered ever since whether this has been used for resuscitation. Searching the literature I found case reports particularly in paeds deliberately using arterial access for delivery of medication and fluids including blood. Still, I’ve never used it but I still wonder as an option.

I’ve for quite a while wondered about the move towards humeral vs prox tibial I/O. I know the reasoning ie pelvic bleeding and abdominal bleeding as well as improved flow rates.

The evidence for flow rates better in the humerus is not overwhelming and one study showing improved flow in tibia. The important aspect of that study was that pressure is required.

One postmortem study found on CT 50% of humeral I/Os were inadequately placed. Including only patients with a yellow needle there were still 5/16 improperly placed.

Is the fear of using the prox tib as an I/O site theoretical or based on evidence? It didn’t seem to worry us when we were taught to perform cutdowns on saphenous veins. I notice on emcrit a video taught by a trauma director still teaching saphenous cutdown at the thigh.

Wouldn’t the valves in veins prevent bleeding from proximal tributaries?

I spent some time during the shift ultrasounding the subclavian v and I’m thinking u/s guided access would be feasible. Before I heard Cliff’s comment about the dwell cath I also thought it would be the most useful catheter in our kit.

Thanks guys for an interesting talk. Andre’s comments regarding lower limb vs upper body venous access are pertinent. It is one of those evidence free axioms in trauma that femoral venous access is inferior in cases of suspected pevicoabdominal injury. I’m not convinced by the thinking behind this. The venacaval system is essentially a single column with no valves. A hole somewhere along this vascular column will bleed in relation to the pressure across it, and this pressure will equilibrate irrespective of where any access is gained. Flow rates of additional infused volumes represent a small fraction of native flow in the IVC/SVC and would not contribute to local increases in pressure along this low impedence system. The exception might be an avulsed IVC. These patients do not survive.
In addition, pelvic venous bleeding is almost invariably from branches of the internal, rather than external iliac vv. These DO have valves, and hence blood loss from these veins is dependent on circulating blood returned from local tissue, not retrograde flow from the IVC or common iliac vv. Ditto a hole in the spleen or mesentery.
None of this has been tested to my knowledge. One method in an animal model of abdominopelvic venous injury would be to quantify the proportion of radiolabelled blood that returns to the circulation when given via a femoral vs supradiaghragmatic access point.
Why is this all relevant? I believe that the advantages of tibial IO or femoral large bore central access in a time critical situation far outweigh the theoretical concerns for increasing blood loss via an injury “below the diaghragm”.
Alex.